versión impresa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.102 no.9 Cape Town sep. 2012

The government's appeal to private healthcare to help it achieve universal coverage had two immediate priorities, namely fighting HIV/AIDs and TB and building human resources, Health Minister, Dr Aaron Motsoaledi, told 900 private healthcare conference delegates in late July.

Detailing discussions he held with the leadership of sixteen top medical aid schemes and managed healthcare companies last year, he told the Board of Healthcare Funders (BHF) annual conference in the Drakensberg on 30 July this year: 'There are a million things you can do, but I'll chose only two for now, two that will change the course of history'. He highlighted the dire shortfalls in human resources for healthcare, saying the industry could lend its extensive skills and experience in finance, accounting and training doctors, nurses, specialists and technicians. 'We want you to help us train and produce them in large numbers. You also have financial gurus and health economists - not those who say what's not possible, but those who say what is. We need to start training people in all these spheres.' He was referring to the alarming analysis in the government's human resources for health strategy document released last August. In it, the country's top actuaries and health economists conclude that hastily re-opened nursing colleges need to churn out 51 200 professional nurses over the next decade while medical campuses will have to double their output of GPs over the next 15 years - just to maintain the current (dismal) healthcare professional-to-population ratios. The full extent of the herculean task required to maintain this status quo - let alone make a dent in the shortfall, shows that at a constant GDP growth rate and with 'concerted investment' for the next 5 years (3 - 5% annual growth rate in health staff spending), it will be possible to close the gap in 'realistic numbers' in 20 years.

Motsoaledi said the result of the former government's policy shift to a university-based primary nurse-training platform was an inverted pyramid with 98 000 professional nurses and 38 000 enrolled nurses. 'So we have a situation where everybody is a commander,' he added wryly. The deans of all eight medical schools had promised to help where possible (with limited impact), while his department would this December send 1 000 matriculants to Cuba for training as doctors. He rebuffed critics of the Cuban training scheme, saying the Cuban health model was based on primary health care in stark contrast to the inappropriate curative South African one. 'The Cubans are the healthiest people on earth. They've eradicated 15 common communicable diseases, we die 28 years earlier than they do, you don't see measles or malaria there and they have one per cent of the burden of HIV - yet our professors believe we are the cleverest!'

A ninth medical school was planned for Limpopo, which together with the Eastern Cape would get the lion's share of the R1.2 billion set aside for revamping nursing colleges between now and 2014. A least five other academic and tertiary hospitals would also either be built (Nelspruit) or totally rebuilt (King Edward VIII, which would include a new faculty of medicine, George Mukhari, Chris Hani/Baragwanath and Nelson Mandela) by 2020.

Regulation 8 and Competition Commission ruling

Switching to the volatile and controversial private healthcare market, he blamed troublesome regulations in the Medical Schemes Act (Regulation 8 on Prescribed Minimum Benefits) and the 2004 Competition Commission ruling (barring medical schemes from bargaining with service providers) for spiralling private healthcare costs. Labelling the current situation 'abnormal and unacceptable' and 'the law of the jungle', he promised legislative amendments to Regulation 8, saying lawyers currently differed on the interpretation of 'pay in full'. The BHF is appealing (to the Supreme Court) a North Gauteng High Court ruling in November last year whose effect is that medical schemes must 'pay in full' at whatever the invoice is for PMBs (270 medical conditions and 25 chronic conditions). 'Taking the case to Bloemfontein is not a solution. It will just kill the patient and favour one party, but not the patient. The judge is ruling on a particular law that parliament must actually change,' he added.

PMBs 'unconstitutional' on several fronts -lawyer

BHF chairman Clarence Mini said in introducing Motsoaledi that since Judge Cynthia Pretorius ruled that the BHF had no standing in the PMB matter there had been an upsurge of PMBs, with doctors registering diseases that did not fall under PMBs as such. Motsoaledi asked: 'What kind of a medical aid system is it where doctors have to lie to get money? We have to go back to parliament and say this gap is being exploited. I may agree that for the time being we keep PMBs, but they can't be charged per invoice. There is no other business I can think of where everything is charged per invoice. Being in hospital now is like being in a supermarket but at least in a supermarket you are certain of prices,' he added, promising a government-led pricing commission.

Advocate Isabelle Ellis of the Pretoria Society of Advocates told delegates that the compilation and promulgation of PMBs was unconstitutional, as the rationale behind the list was disease-based as opposed to being based on an essential health service. The lack of cost and tariff guidelines associated with PMBs also rendered the list unconstitutional. She said the object of PMBs was to improve efficiency in the allocation of private and public health resources. 'We all know the State cannot provide access to all without the help of medical schemes. The National Health Act preamble states that the purpose of the act is to unite the various elements of the national health system to improve national health and promote a spirit of cooperation and shared responsibility. It entails all the elements around the principle of complementarity,' she added.

Picking and choosing various diseases was not the object of primary or essential healthcare and therefore rendered the PMBs unconstitutional and discriminatory. The regulation did not provide for the principle of complementarity when it came to members of medical schemes. 'Put simply, the object of complementarity was to ask medical schemes to include that which national health policy must provide for your members. This can only happen on the same basis that national health is provided to the rest of the population. Anything else would be unfair to members of medical schemes,' she added.

Turning to the NHI, Motsoaledi revealed that GPs had been invited in all 10 NHI pilot districts to chose a clinic and give four (paid) hours of their time per week as a 'dry run' for involving private practitioners. He quoted World Health Organization chief, Dr Margaret Chan, as saying universal healthcare coverage was 'a powerful equaliser that abolishes distinctions between rich and poor, the privileged and marginalised, young and old, ethnic groups and men and women ... the ultimate expression of fairness and ... our saviour from the crushing weight of chronic non-communicable diseases that now engulf the globe'.

'Uncontrolled commercialism' destroying universal care

Motsoaledi said he took severe 'flak' for speaking about 'uncontrolled commercialism', yet this came from none other than Chan herself. 'I'm not speaking about just the private healthcare sector and pricing but the public sector where we've replaced a public health care system with a tender (prenurial) health care system; the tender comes first and health second. Unless we deal with this uncontrolled commercialism, the entire system will collapse,' he said.